Download Wound healing pathway

Wound healing pathway
Carry out initial wound assessment using Oxford Health’s Wound Assessment Form
Consider and record evidence on the following criteria: (Please refer to the guidance on
the back of this pathway)
Are there any general and/ or systemic factors that
may affect healing outcome?
Are there any wound specific factors that may affect
the healing outcome?
For referral guidance please contact:
Phone: 01235 205786/01235 208755
Fax: 01235 205788
Email: [email protected]
Are there any concordance factors that may affect the
healing outcome?
Are there any resource and/ or skill factors that may
affect the healing outcome?
Have any specific factors been identified that cannot be addressed or could make the wound hard to heal?
YES
This is a hard to heal wound
Refer immediately to community tissue
viability service
NO
Establish and document treatment goals, timelines and a
plan of care which will address the factors identified at
assessment.
Set a reassessment date
(See above for guidance on referral)
The need for advanced wound products
may need to be considered
YES
Reassessment
Measure outcomes from initial or last assessment
Does anything suggest this wound is not healing,
is slow to heal or will not heal?
Wound healing pathway/ V1 Tissue viability Z drive/ feb 2012
NO
Guidance for assessing hard to heal wounds
Please tick any box that relates to the patient you are assessing. The greater the number ticked, the more at risk the wound is
of being Hard to Heal.
General
Tick
Medication includes steroids, cytotoxic
therapy or warfarin.
Impaired mental capacity (inability to make
informed decisions)
Systemic
Tick
Poor perfusion/ ischaemia/ peripheral vascular disease
Anaemia
Social isolation
Auto -immune disease – i.e. rheumatoid arthritis, lupus etc
Diabetes mellitus
Health & social care needs
End of life status
A carer for others
Poor nutritional status
Financial/ employment issues
Immobility
Pain
Smoker
Wound specific
Tick
There has been less than 40% reduction of wound surface area after 6 weeks of treatment
If ticking this box then please refer immediately to tissue viability
Wound of a duration greater than 24 weeks
Wound larger than 100cm² or a length equal to or greater than 10cm
A wound deeper than 5mm, undermining or tracking (sinus/ cavity)
Heavily exuding wound
Devitalised tissue (Slough/ necrosis) in wound bed
Maceration and/ or excoriation to wound edges
Local wound bed infection (Critical colonisation)
Systemic wound infection (Cellulitis)
Oedema/ lymphoedema in affected limb
Wound malignancy
Full thickness wound, Exposed tendon, bone exposed
Concordance – consider:
Tick
Is it related to uncontrolled pain?
Is it related to a lack of understanding or lack of mental capacity
Could it be related to fear/ anxiety/ depression
Is it related to you as a health care provider? i.e. The day/ time of visits or appts, the competence of
staff, nurse/ patient relationship, interpersonal skills, lack of empathy.
Resource/ skill specific – consider:
Lack of adequate equipment available.
No or limited access to the dressings required for managing this wound.
No or limited access to specialists to support you with this wound.
No or limited access to education and training to enhance wound care knowledge & skills
Wound healing pathway/ V1 Tissue viability Z drive/ feb 2012
Tick